Abstract
I write the editorial for this issue of Obstetric Medicine as I prepare to travel to the annual course on Medical Problems in Pregnancy in London that is held at the Royal College of Physicians of London. It is organized by Catherine Nelson-Piercy, Catherine Williamson and David Williams and for any of you who have not taken advantage of this exceptional course, I would encourage you to do so. It provides an excellent practical overview of all the key topics in Obstetric Medicine given by some of the best experts in the field. However, despite the excellence of this course, I am struck by how much of what I look forward to about this course - or in fact any Obstetric Medicine conference - is not just the learning opportunity it provides, but also the opportunity to interact with the unique people who invariably work in this field.
Why is this so and what relevance does this observation have to the practice of Obstetric Medicine?
I think we would all agree that at the heart of the practice of Obstetric Medicine is the overwhelming need to educate ourselves and others about the care of medical illness in pregnancy, while creating new knowledge in our field through rigorous case series, review articles and new research. In this month's issue of Obstetric Medicine, we review two important conditions that may impact but not prevent pregnancy. Stage 1 chronic kidney disease is the mildest end of the renal disease spectrum and in this review Podymow and August summarize current knowledge about diagnostic challenges, pregnancy outcomes and the impact of pregnancy on the natural history of mild renal disease. Congenital adrenal hyperplasia (CAH) is a complex heterogeneous condition with variable phenotype and genetics. The management of this condition in pregnancy is a classic model of managing two patients simultaneously: mother and fetus. In their comprehensive review, Keely and Malcolm discuss appropriate preconception counselling and subsequent management of the woman with CAH and the fetus. Pre-eclampsia remains one of the most perplexing of medical conditions we face. The history of its study has often centred on its relationship to key physiological molecules we find associated with this condition. In their article, Spaan and Brown place the relationship between the renin-angiotensin system into a historical context and explain how this important system integrates into our current understanding of the pathophysiology of this most important complication of pregnancy.
However, while these excellent articles demonstrate the knowledge and science of Obstetric Medicine, to my mind this work is necessary, but not sufficient, for our success as doctors caring for medical illness in pregnancy. Arecent article published in the Journal of the American Medical Association 1 by a physician leader in Quality and Safety from Toronto, puts forth the experienced opinion that patients value information about aggregate outcomes and success rates less than they do kindly, coordinated, timely care provided by individuals who demonstrate empathy and instil a sense of confidence in their patients. I think that these qualities are characteristic of most of the practitioners in our field. How did these traits - so beneficial to the patients we serve - come to be so concentrated in this field? I think it has something to do with the fact that anyone who is willing to pursue a special interest in the care of medical illness in pregnancy has self-selected themselves and been tested on their journey to identify themselves as the kind of medical practitioners that I find worth travelling to get together with.
To my mind, the care of medical illness in pregnancy is a peculiar career choice about which you must be passionate in order to undertake. It is certainly not associated with any particular economic advantage for most of us. It is also not a path that is full of prestige or recognition. (I would be a rich man if I had a dollar for every minute I have spent in my life explaining exactly what it is that I do for a living!) Instead, it is a career path that often comes with considerable personal sacrifice. Many of us have had to take unconventional training routes to get the skills we need. We have then had to advocate hard for jobs that did not previously exist. Once successful, we find ourselves working with call schedules and middle of the night obligations that are different from many of our peers in other fields. And despite this dedication, we can at times find ourselves in situations where our unique training is not always appreciated or understood as much as it might be. The care of medical illness in pregnancy itself is also demanding both intellectually and emotionally. We routinely deal with stressful situations in which the stakes are very high for all involved, and there is often very little hard data to guide our care recommendations. Lucia Larson, a past president of the North American Society of Obstetric Medicine, once told me something I have often repeated to myself when I see a particularly challenging case: ‘Obstetric Medicine training is in no small part learning to feel comfortable with feeling uncomfortable’.
So what is it about the unique people who end up in this field that makes them such compelling company for me? And why am I taking time to write about it here in our professional journal? Well, I think the question of what makes it so pleasant to assemble as Obstetric Medicine physicians goes to the very heart of an essential element of the care of medical illness in pregnancy of which many of us are aware but rarely talk about. It is my observation that most, if not all, of the people who pursue this field, despite these many challenges, are people who are characterized by a passionate dedication to the specialty, a compassion and kindness for their patients, a broader vision to make a difference and a relentless tenacious belief in their mission and a desire to ‘spread the word’. All of these traits are coincidentally characteristics of people that I consider to make exceptional company. The complex needs - emotional, intellectual and physical - of the medically compromised pregnant women cannot be met by exceptional clinical acumen alone. This quarter's edition of the journal offers some good examples of the scholarly work so critical in our field and the wellbeing of the future of the patients we serve. However, in many of the cases relevant to these works, we are left with the distinct knowledge that although we can help guide women with medical illness through a pregnancy, our ability to ensure a good outcome is not what we would like it to be. This brings me to the point of this editorial - that an essential element of the practice of our field is that personal dedication and caring that makes the practitioner who focuses on medical illness in pregnancy a worthwhile guide and partner for a woman and her family as she journeys through a potentially difficult pregnancy. So while you enhance your knowledge in our field reading through the good work in this edition of the journal, consider also those traits necessary to its useful application - and the good company that those skilled both in its development and its application make.